1. Management of Breast Cancer Post graduate Studies and ResearchBy
Hussein M. Khaled
Prof. Medical Oncology
Vice President
Post graduate Studies and Research
Cairo University

2. BREAST CANCER Worldwide incidence in females*
Western
Europe
67.4
36.0
28.6
71.7
21.2
25.0
31.5
25.5
86.3
Eastern
Europe
Japan
Australia/
New Zealand
South Central Asia
Northern
Africa
1. Breast Cancer: Worldwide Incidence in Females
Breast cancer is the third most frequent cancer worldwide and the most common malignancy among women (21% of all new cancer cases). Incidence rates are high in all developed countries, except Japan, and highest in North America with 86.3 cases per 100,000. Incidence rates for selected countries are shown on the map.
Southern
Africa
Central
America
North
America
*Incidence per 100,000 population.
Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.

3. CANCER CONTROL
EARLY
DETECTION
PRIMARY
PREVENTION
DIAGNOSIS
TREATMENT

4. BREAST CANCER Signs and symptoms at presentation
Mass or pain in the axilla
Palpable mass
Thickening
Pain
Nipple discharge
Nipple retraction
Edema or erythema of the skin
16. Breast Cancer: Signs and Symptoms at Presentation
Although the use of mammography is increasing, more than 80% of all breast cancers are still diagnosed as a result of symptoms, most often a painless mass. However, as many as 10% of patients present with breast pain and no mass. Less common symptoms include nipple discharge, nipple erosion or ulceration, diffuse erythema of the breast, axillary adenopathy, and symptoms associated with distant metastases.

6. BREAST CANCER Diagnosis path
Evaluation
for
biopsy
Cyst
Normal
Palpable mass
Nonpalpable
mass
Cyst
aspiration
22. Breast Cancer: Diagnosis Path
Any dominant breast mass lesion should be biopsied.
Biopsy
Excisional biopsy
Core-cutting needle biopsy
Fine-needle aspiration
Needle
localization
If persistent, short-term
follow-up
with surgeon
Continued
appropriate
screening
Insufficient
evaluation,
rebiopsy
Ductal
carcinoma
in situ
Invasive
cancer
Lobular
carcinoma
in situ
Benign
Treatment Path

7. Staging Classification of Breast Tumour

9. Early Breast Cancer

12. NSABP B-06: Effect of Lumpectomy v. Mastectomy on Survival
Cohort A
Cohort B
Cohort C
DISTANT DISEASE-FREE SURVIVAL (%)
YEAR
No. of patients / No. of recurrences
Total Mastectomy:
692/265
569/233
494/192
Lumpectomy:
699/302
634/282
520/236
Lumpectomy + XRT:
714/278
628/253
515/204

14. HT

17. HER2 testing algorithm + – FISH/CISH Patient tumour sample IHC 2+ 3+1+
Herceptin® therapy
Adapted from Bilous M, et al. Mod Pathol 2003;16:173–82 Hanna W. Breast 2005;14(Suppl.1)S17 (Abstract 10)

18. Locally Advanced Breast Cancer

26. What elements drive therapy decision making ?
Prognosis
Treatment
toxicity
Co morbidity
Treatment
efficacy

27. GUIDELINE RECOMMENDATION
FOR CHEMOTHERAPY FOR
STAGE I BREAST CANCER
T1a (0-5 mm)
T1b (6-10 mm)
T1c (11-20 mm)
NCI
ER +
NCCN*)
ER -
This slides summarize the real problem, 3 standards all pretending the classification low-high risk
Three gold standards makes it a little bit busy and to be spoilt for choice highlights the real issue that the gold standard is not that shiny at all, not to mention all local adapted variants on these standards
Also if ones wander away from the standard one enters non validated territory
Maybe it is time for one new gold standard?
MammaPrint?
ER +
St. Gallen
ER -
Optional
Recommended
Not Recommended
*) NCCN = National Comprehensive Cancer Network 27

28. www/Adjuvant on line !

29. The Breast Health Global Initiative (BHGI) Guideline Publication 2003
CONSENSUS STATEMENTS
Early Detection Panel
Diagnosis Panel
Treatment Panel

30. BHGI GLOBAL SUMMIT 2005: Guideline Stratification
Breast J 2006;12 Suppl 1:S

31. Diagnosis

32. Controversial Issues :
FNAC or Frozen Sections
5 or 10 years of HT
T and AI
Type of CT
Herceptin and others
Pre or post op CT
Ov ablation
Cases who do not need systemic treatment

33. Application of cancer treatment
Cost of cancer treatment

34. Situation Analysis Egypt

35. Gharbia Population–based registry
EGYPT
Gharbia Population–based registry

36. Incidence Rates of Common Sites of Cancer Population Data: Females
Rate per pop.

37. GLOBAL STATISTICS: Age-Specific Rates / 100,000 Females (all ages)
Globocan 2002 (IARC)

38. The National Cancer Institute Cairo University www.nci.cu.edu.eg

39. NCI Most Common Sites in Males and females

40. National Cancer Registry

41. Age structure of Female breast cancer patients.
Cumm. %
Proportion
7.7
20.3
35.1
52.7
68.9
79.3
90.5
95.5
100.0
12.6
14.8
17.6
16.2
10.4
11.2
5.0
4.5
<35
35-
40-
45-
50-
55-
60-
65-
70+

42. Age-specific Incidence Rates of Breast cancer in younger age groups: Egypt and US SEER
1.3
7.1
25.2
61.7
117.5
192.1
253.1
1.4
9.8
28.9
63.6
96.7
171.5
181.2
20-24
25-29
30-34
35-39
40-44
45-49
50-54 ……

43. Magnitude of Breast Cancer in Egypt: 2025
Projection of Magnitude of Breast Cancer in Egypt: 2025, 2050
Magnitude of Breast Cancer in Egypt: 2025
Population size: million females
Crude incidence rate: 55.1./100,000 females
Incidence: 14,000  28,000 breast cancer cases
Prevalence: 42,000 84,000 breast cancer cases
Magnitude of Breast Cancer in Egypt: 2050
Population size: million females
Crude incidence rate: 68.8./100,000 females
Incidence: 14,000  44,000 breast cancer cases
Prevalence: 42,000 132,000 breast cancer cases

44. Breast cancer T stage 1984 - 2006, Port Said, Egypt
SOURCE: Prof. Dr. Ahmed Elzawawy

45. Cancer Control in Egypt

46. Inflammatory Breast Cancer (IBC)
Swollen
Erythema
Peau d’Orange
Frequently Mistaken for Mastitis

47. Clinico–Pathological Correlation in Breast Cancer Cases (2002)
Revision of the slides of 212 patients.
Only 16 patients had both clinical and pathological features of IBC (8%)
Age distribution
4 patients
35 yrs or less
8 patients
45 yrs or less
More than 45 yrs
The youngest
25 yrs
The oldest
76 yrs

48. “ Immunphenotypic signature”
Biologic profile
“ Immunphenotypic signature”
More than 90% of IBC showed positive axillary nodes.
IBC’s are characterized by:
High histologic grade tumors with high Nuclear grade, necrosis and high PCNA and MIB-1(Ki-67) labeling indices.
ER & PgR are frequently negative.
p53 > 70% positivity.
HER-2/Neu > 60%.

49. Tumor emboli and LYVE-1 and RhoC expression in IBC tumors from Egypt and the United States

50. RhoC Scoring and Tumor Emboli for Egyptian patients with IBC and non-IBC
IBC (N=46)
No. (%)
Non-IBC (N=64)
P-value
RhoC Score 1 2 3 4
1 (2)
5 (10)
(44)
20 (44)
24 (38)
29 (45)
7 (10)
4 (6)
<0.0001
RhoC Categories
1-2
3-4
6 (13)
40 (87)
53 (83)
11 (17)
Tumor Emboli
Mean ± SD
0-1
2-8 9+
14.1 ± 14.0
(41)
26 (57)
7.0 ± 12.9
32 (50)
18 (28)
14 (22

53. Thank you
Cairo University
National Cancer Institute